It's your 6 week postpartum check up, and your provider gives the all clear to give your partner some long-awaited alone time. Everything looks great! So, why is the thought so terrifying?
You're definitely not alone. Most of the women I work with admit that the idea of reintroducing intimacy after childbirth is more intimidating than it is enticing, but with some preparation, the experience may prove to be more enjoyable than you expect.
First, it's important to remember that your body is built to create and bring forth life. Your pelvis and all of its intricately designed soft tissues, connective tissues, joints, and organs are designed for this task, and as such, are designed to heal, return to their former size, length, function, and support you throughout your life. Just like any activity, it may take your muscles some time to readjust to the exercise of intercourse, and some women need a little extra help in the form of rehabilitation along the way. But in any case, there are options to assist you in this endeavor no matter what the details of your delivery may have been.
The reason why 6 weeks tends to be the general rule of thumb for "return to duty" postpartum, is because this is the approximate amount of time the body needs in order to heal any soft tissue damage (ie tearing or episiotomy - 8 weeks for cesarean section) that may have occurred during delivery. This also includes the approximate "healing" time of the uterus, though research is now beginning to suggest that it actually takes 2.5 years for the body to fully recover from pregnancy and delivery in total. When I say this to my patients, they are usually somewhat disappointed. We live in a society that demands women achieve their beach-ready-body as quickly as possible, leaving no sign or trace of pregnancy as they care for their brand new human being. However as a Physical Therapist, I think 2.5 years is great news! This means that whatever gains or lack of gains you may have made in 6 weeks, there is still plenty of time to make more improvement. You have 2.5 years to allow your body to heal naturally and to reach your goals. Now, most of us are usually pregnant again before this timeline has reached its end (in my case, well before), but that doesn't mean improvements cannot be made.
Sitz Bath
Many women in Western culture are beginning to return to our Earth-grown roots and remember that medicine originated in nature. Plants contain powerful healing properties and have been used for centuries to aid the human body in its natural processes. You are your healer. No medicine or plant can do that for you, but herbs have the ability to assist your healing with little to no side effects, toxic chemicals, or long-term adverse symptoms. Popularity of the old tried and true Sitz Bath is returning to modern culture, and with good reason. It works! Steeping your healing perineum in a tea of soothing herbs has been shown to reduce swelling, staunch excess bleeding, minimize pain, and improve overall healing time of the tissues. The basins that easily fit atop your toilet can be found just about anywhere from CVS to Amazon, and they are usually very reasonably priced. I tend to get all of my own herbs from Mountain Rose Herbs due to their high quality and low chemical use, but again, herbs are making a come back! You might find them locally wherever you are. Here is a small list of the ones most commonly used for Sitz Bath:
Yarrow - bleeding
Calendula - inflammation
Lavender – inflammation and anti-bacterial
Comfrey - connective tissue healing
Aloe Vera - burning
Witch Hazel – inflammation
Marshmallow – mucosa healing
Simply steep a mixture of your choice in about 8oz of hot water for around 5-10 minutes to create a very strong tea. Strain out the herbs and pour the tea into your Sitz basin of warm (not hot) water and settle your perineum into it for a few minutes. Most recommendations suggest 20 minutes, but honestly, my legs go numb if I sit that long. 5-10 minutes, 2-3 times a day still works great. After the bath, air or gently pat dry (don't rub) and apply any ointments or sprays as usual.
When I was healing from my third delivery, I really did not have the time to sit in my Sitz anymore! So, my solution was to create a Sitz Bath Salve, which is used as an ointment that I applied multiple times per day rather than taking my bath. You can find that recipe here.
Lubrication
Many women are disappointed to find that their natural ability to produce vaginal lubrication reduces after baby. There are many reasons for this, as you may read in my post here, but the main idea is that you (or your partner) should not judge your sexuality or sexual readiness by your amount of lubrication. Instead, expect that against all of your efforts, production just may not be up to par after baby. Your first attempt at intercourse postpartum should not wait until discomfort to invite a supplemental lubrication. Start out with it! The less uncomfortable friction on newly healed tissues the better, and the least likely you will find that your brain asks your pelvic floor muscles to tighten up and guard against penetration. It's a real thing! The majority of women that I treat for dyspareunia (painful intercourse) have a neurological system that is hypersensitive to stimulation of the perineum, and is protectively guarding against anything entering, causing pain. We can help prevent this from the very beginning with a good supplemental lubrication and a little patience.
Scar Tissue
Myofascial adhesions - or "scar tissue" - form as a natural part of the body's healing process. Collagen is the glue that binds everything together, but it's not always perfect. In fact, most of the time scar tissue is restrictive to the use and movement of the very things it has healed. The body is a marvelous machine, but it's also designed for procreation and survival at any means. Taking the time to heal damaged tissues exactly as they were before would require that you regrow that tissue, and that takes much longer to do than just slapping down some collagen and calling it a day. Scar tissue in the perineum can restrict the ability to easily accept penetration and stretching, making it uncomfortable or even painful in the beginning. Again, this is very treatable. When working with patients in my practice, I use gentle internal manual therapy techniques to gradually and slowly stretch the tissues over time. At home, you may accomplish the same thing with devices designed specifically to do so. These are called dilator systems. I highly recommend the ones made by Intimate Rose as the owner and designer is a Pelvic Floor Physical Therapist, but you may find many different brands online. Working with dilators before intercourse may pre-relax and stretch the perineum in a slow and gentle way which you are in total control of. This part is important: many women find they become tense when their partner begins to move during intercourse because they are anticipating that it will be painful. Working with dilators before penetration, along with deep breathing, stretching, and even external foreplay can be the ticket in allowing you to relax and enjoy your partner without the stress.
Muscle Tone
Muscles of the pelvic floor are exactly the same muscle type that exists in your shoulders, your back, your legs, etc. And just like those areas, your pelvic floor can develop tight, achy muscles and trigger points. Dilators may or may not be helpful with this issue depending on which muscles are causing the pain and where, but that's where I come in. Pelvic Floor Physical Therapists, are highly trained in the anatomy and gentle techniques for alleviating tension and pain in the muscles. Once we've identified where the pain is and why, it is usually appropriate to go ahead and assign another pelvic floor tool known as a "pelvic wand". Unlike the dilators, they are designed with a curved spine which allows you to easily reach tight internal muscles and work on them yourself outside of therapy sessions. Having a thorough PT evaluation will help you to better determine which option is best for you, and how to use them.
The Overused Kegal
Most women are at least familiar with the name, even if they don't have a clue how to execute it. And that's the problem! The Kegal is just one tool in an entire spectrum of different techniques used to rehabilitate the pelvic floor, and it's not always appropriate for every woman depending on her stage of rehab. The Kegal is used a lot as a one-stop-shop in fixing all things pelvic floor, but its really nothing more than a pelvic floor muscle contraction. Now, take your hand and make a fist as tight as you can. Tighter. Now, try to squeeze even tighter and then relax. Ouch, right? And almost impossible. Asking a tight or "short" pelvic floor to contract when it's already as tight as it can get can make things worse if tightness is the issue already. It's always best to assume that your pelvic floor needs lengthening before strengthening, and to start with a very relaxing program of breathing and stretching before attempting the Kegal.
Pre-Sex Program
Try this basic program on for size, and remember to be patient with your body. Get help from a PT in your area, it can make all the difference in the world. It's what we do! They will be able to design a program that is most appropriate for you.
Lay comfortably on your back with legs up the wall or headboard of your bed
Take 10 deep, slow belly breaths - focus on allowing the breath to fill your pelvis and stretch your pelvic floor gently. This should be passive, do not "push" your pelvic floor.
Bend the knees and place feet on the wall, allowing the legs to open like you're squatting on your back.
Take 10 more breaths
If you have a dilator, you may introduce it here for about 5 minutes.
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